Your Social Security Number

THE CITY OF NEW YORK

___ ___ ___ - ___ ___ - ___ ___ ___ ___

DIVISION OF CITYWIDE PERSONNEL SERVICES

FOR DCAS USE ONLY

DCAS Application Section

1 Centre Street, 14th Floor New York, NY 10007

RATING

EDUCATION AND EXPERIENCE TEST PAPER (EETP)

Do Not Write Your Name Anywhere On This EETP.
Type or Print All Required Information In Black Or Blue Ink.

Exam Type:

(check only one)

Open Competitive

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NQ CODE

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SEL CERT

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________________
________________ _
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RATER(S)

Promotion

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CME

Exam Title:

Exam Number:

______________________________________________________________

____ ____ ____ ____

This test is based upon your education and experience. In order for you to obtain appropriate credit, it is necessary for you to
complete this form accurately. If you need more space, attach additional sheets, using the format specified here. Be sure
to include your social security number and the exam number on each attached sheet.

SHADED
COLUMNS

The information you enter on this form must be verifiable. If information is missing, illegible, unclear, or lacks necessary
detail, you may be found "Not Qualified" or receive a lower score on the test. You may be disqualified if your statements
are found to be false, exaggerated, or misleading.

ARE FOR

Refer to the Notice of Examination (NOE) to find out which sections of this form you must fill out. If you are applying for
Selective Certification, be sure to complete Section D on page 4 of this form.

USE ONLY

DO NOT attach your resume.

Resumes will not be rated.

SECTION A - EDUCATION

DCAS

FOR DCAS
USE ONLY

Section A.1 - FOREIGN EDUCATION EVALUATION

In order for foreign education to be rated, it must be evaluated by an evaluation service approved by DCAS. Follow the
instructions on the Foreign Education Fact Sheet, and refer to the Notice of Examination to see which kind of evaluation is
required for this test. If you are claiming credit for foreign education, check one of the following:
For this examination,
_____ I am having an evaluation of my foreign education submitted directly to DCAS by an approved evaluation service.
_____ I wish to use an evaluation of my foreign education which was previously submitted directly to DCAS by an approved evaluation service.
Section A.2 HIGH SCHOOL OR HIGH SCHOOL EQUIVALENCY (GED)
CIRCLE THE HIGHEST GRADE OR YEAR OF HIGH SCHOOL (HS) COMPLETED:

Did you graduate HS?

Yes ______/______ No
Month

8
Month

High School located in the State of: _______________________________

Yes

______/______
Month

No

10

11

12

FOR DCAS
USE ONLY

Dates of Attendance: From ______/______ To ______/______

Year

Name of High School: ____________________________________________________________

Do you have a GED?

9
Year

Month

Year

USA Foreign

Country of: ____________________________

Name of Agency issuing GED: ___________________________

Year

(If you attended other high schools, report this information for each
additional school on a separate sheet of paper using the same format)

Section A.3 TRADE SCHOOL OR VOCATIONAL HIGH SCHOOL

FOR DCAS
USE ONLY

If you attended a trade/vocational school, please complete the following:

Did you graduate?

Yes

______/______
Month

Year

No

Dates of Attendance: From ______/______ To ______/______

Month

Name of Trade/Vocational School: ___________________________________________________

Trade/Vocational School located in the State of: _____________________________
Specialty ______________________________________

Year

Month

USA Foreign

Country of: ______________________

Number of hours you completed in specialty: _____________

(If you attended other trade or vocational schools, report this information for each
additional school on a separate sheet of paper using the same format)
DP - 1000 (Rev. 09/2010)

Year

Exam Number: ___ ___ ___ ___

Your Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Section A.4 UNDERGRADUATE EDUCATION

Name of Undergraduate College/University: _____________________________________________

USA Foreign

FOR DCAS
USE ONLY

Address: _______________________________________________________________________________________________
State: _____________________________________________

Country: __________________________________________

Major: ____________________________________________

Credits are: (check only one) Semester/Trimester Quarter

Number of Credits You Have Completed in Major: _________

Total Number of Credits You Have Completed: ____________

Do you have a Degree?

Yes No

Dates of Attendance: From ______/______ To ______/______

Month

Date Degree Received: _________________

Type of Degree: (check only one)

Year

Month

Year

Associate Baccalaureate

Exact Title of Degree: ___________________________________________________________________________________

(If you attended other undergraduate institutions and/or obtained more than one degree, report
this information for each additional institution on a separate sheet of paper using the same format)

Section A.5 GRADUATE EDUCATION

Name of Graduate School/University: __________________________________________________

USA Foreign

FOR DCAS
USE ONLY

Address: _______________________________________________________________________________________________
State: _____________________________________________

Country: __________________________________________

Major: ____________________________________________

Credits are: (check only one) Semester/Trimester Quarter

Number of Credits You Have Completed in Major: _________

Total Number of Credits You Have Completed: ____________

Do you have a Graduate Degree?

Yes No

Dates of Attendance: From ______/______ To ______/______

Month

Date Degree Received: _________________

Year

Month

Year

Type of Degree: (check only one) Masters Doctorate Other: __________

(specify)

Exact Title of Degree: ___________________________________________________________________________________

(If you attended other graduate institutions and/or obtained more than one degree, report
this information for each additional institution on a separate sheet of paper using the same format)

Section A.6 COURSES

Refer to the Notice of Examination to find out if this section applies to you. If it does, complete this section listing ONLY
those courses you have successfully completed that are necessary to meet the requirements or qualify for extra credit as
specified in the Notice of Examination. In the column headed "Level", print "U" for an undergraduate course, "G" for a
graduate (post-baccalaureate) course, or "T" for a union training, trade, Vocational HS, or apprenticeship program. You must
specify whether you are reporting time in hours or credits.
Name and Address of
Institution/College/Trade School

Course No.

Exact Title of Course

___________________________

_________

________________

___________________________

_________

___________________________

Level
(U/G/T)

# of Credits

# of Hours

Date
Completed

______

________

_______

_________

________________

______

________

_______

_________

_________

________________

______

________

_______

_________

___________________________

_________

________________

______

________

_______

_________

___________________________

_________

________________

______

________

_______

_________

___________________________

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________________

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________

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_________

___________________________

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________________

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________

_______

_________

___________________________

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________________

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________

_______

_________

___________________________

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________________

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________

_______

_________

___________________________

_________

________________

______

________

_______

_________

(Use additional paper, filled out in the same format, if needed)

Page Two

FOR DCAS
USE ONLY

Exam Number: ___ ___ ___ ___

Your Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION B EMPLOYMENT / WORK EXPERIENCE (PAID OR VOLUNTEER)

Refer to the Notice of Examination to see whether this section applies to you. If it does, describe your THREE most recent relevant jobs using
the format below. You may describe other relevant jobs by adding additional sheets in the same format. Use a separate box for each job.
Number any additional job BOX 4, 5, 6 etc. IF YOU HAD A SUBSTANTIAL CHANGE OF DUTIES OR A RETURN TO WORK AFTER
A BREAK IN SERVICE WITH THE SAME EMPLOYER, TREAT THESE AS SEPARATE JOBS. List the percentage of time spent on each
duty, task, or function. The total of these percents should equal 100 percent for each job reported.
Include relevant part-time and volunteer experience. Describe relevant armed forces experience. If you are or have been in business for
yourself, enter "self employed" on the line labeled "Name and Address of Employer." You should not reveal your name anywhere on this test
paper.
A maximum of one year of experience will be credited for each 12-month period. Part-time experience will be pro-rated.
You are not limited to the space provided in each box. You can report the information for each
additional employment on a separate sheet of paper using the same format.

BOX 1

Most Recent Employment: From: _______/_______ To: _______/_______

Month

Year

Month

Total Time: _______/_______

Year

Year(s)

Month(s)

FOR DCAS
USE ONLY

Job Title: ____________________________________ Other name of your Job Title, if any: ____________________________
No. of Hrs. Worked per Week ___________

Starting Salary $ _______ per _______

Last Salary $ _______ per _______

If employed with New York City or State, was this appointment: (circle only one) Permanent / Provisional / Other ______________
(specify)

Name and Address of Employer: ____________________________________________________________________________

Title of Immediate Supervisor __________________________________ Nature of Employer's Business __________________
If you directly supervised staff, enter title(s) and number of people: ________________________________________________
If you indirectly supervised staff, enter title(s) and number of people: _______________________________________________
Describe your duties/ tasks/ functions

% Time

Total Time Spent Performing These Duties =

BOX 2

Most Recent Employment: From: _______/_______ To: _______/_______

Month

Year

Month

100%

Total Time: _______/_______

Year

Year(s)

Month(s)

Job Title: ____________________________________ Other name of your Job Title, if any: ____________________________
No. of Hrs. Worked per Week ___________

Starting Salary $ _______ per _______

Last Salary $ _______ per _______

If employed with New York City or State, was this appointment: (circle only one) Permanent / Provisional / Other ______________
(specify)

Name and Address of Employer: ____________________________________________________________________________

Title of Immediate Supervisor __________________________________ Nature of Employer's Business __________________
If you directly supervised staff, enter title(s) and number of people: ________________________________________________
If you indirectly supervised staff, enter title(s) and number of people: _______________________________________________
(Describe your duties/tasks/functions for BOX 2 on Page Four)

Page Three

FOR DCAS
USE ONLY

Exam Number: ___ ___ ___ ___

Your Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

BOX 2 (Continued)

% Time

Describe your duties/ tasks/ functions

Total Time Spent Performing These Duties =

BOX 3

Most Recent Employment: From: _______/_______ To: _______/_______

Month

Year

Month

100%

Total Time: _______/_______

Year

Year(s)

FOR DCAS
USE ONLY

Month(s)

FOR DCAS
USE ONLY

Job Title: ____________________________________ Other name of your Job Title, if any: ____________________________
No. of Hrs. Worked per Week ___________

Starting Salary $ _______ per _______

Last Salary $ _______ per _______

If employed with New York City or State, was this appointment: (circle only one) Permanent / Provisional / Other ______________
(specify)

Name and Address of Employer: ____________________________________________________________________________

Title of Immediate Supervisor __________________________________ Nature of Employer's Business __________________
If you directly supervised staff, enter title(s) and number of people: ________________________________________________
If you indirectly supervised staff, enter title(s) and number of people: _______________________________________________
Describe your duties/ tasks/ functions

% Time

Total Time Spent Performing These Duties =

100%

SECTION C LICENSES AND CERTIFICATES

Refer to the Notice of Examination to see if a license or certificate is required. If it is, and you possess this license or certificate, fill in
the following information. You may describe additional licenses or certificates on a separate sheet of paper using the same format.

FOR DCAS
USE ONLY

Title of License or Certificate: _____________________________________________________________________________

Issued by: _____________________________________________________________________________________________
Date Issued: _____________ License Number: _______________________________ Expiration Date: _________________
(When listing a driver license, be sure to indicate class and relevant endorsements and restrictions.)

SECTION D SELECTIVE CERTIFICATION(S)

If you want to apply for Selective Certification as described in the Notice of Examination, complete this section.
I am requesting selective certification(s) for: _________________________________________________________________.
(If selective certification is for foreign language, specify the language(s)
for which you are requesting selective certification.)
`

Page Four

FOR DCAS
USE ONLY